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Background: Peptic ulcers in patients on aspirin are associated with Helicobacter pylori infection. We investigated whether H. pylori eradication would protect against aspirin associated ulcer bleeding Methods: The Helicobacter Eradication Aspirin Trial (HEAT) was a randomised placebo-controlled trial (EudraCT 2011-003425-96), conducted in UK primary care using routinely collected clinical data. Consenting patients aged >60 years prescribed aspirin < 325 mg but not ulcerogenic or gastroprotective medication underwent C13 urea breath testing for H. pylori. Those with a positive test were randomised to receive either a combination of clarithromycin 500mg, metronidazole 400 mg and lansoprazole 30mg, or placebos twice daily for seven days . Follow up was by scrutiny of electronic data in primary and secondary care. The primary outcome, time to hospitalisation due to definite or probable peptic ulcer bleeding, was analysed by Cox proportional hazards methods

Background Falls are a major cause of mortality and morbidity in older adults worldwide, yet those who are more physically active have a lower risk of falling. There is little information on which participants are most likely to complete falls prevention exercise programmes and increase their levels of physical activity (PA). This study aims to identify factors associated with completion of, and PA levels, at the end of the Falls Management Exercise (FaME) falls prevention exercise programme, a programme designed to increase balance and functional capacity, increase bone and muscle mass and reduce fear of falling. Methods 356 community-dwelling adults provided routine data. Characteristics of participants were compared at baseline. Comparison of activity levels between completers and non-completers were carried out, and a regression analysis performed to identify factors associated with programme completion and achievement of 150 minutes of moderate to vigorous physical activity (MVPA) per week. Results 143 participants completed the FaME programme. This group was significantly younger (range 50-96; mean=75.3, SD=8.1 in completers vs. mean=77.8, SD=8.3 in non-completers) and had significantly lower scores on the FRAT (median=1, IQR=0-2 in completers vs. median=2, IQR=1-3 in non-completers) and FES-I risk assessments (median=10, IQR=7-13 in completers vs. median=11, IQR=8-16 in non-completers) at baseline, and a significantly higher level of physical activity (PA) per week (median=673 minutes, IQR=252-1252 in completers vs. median=558, IQR=120-1127 in non-completers). Completers significantly increased their total minutes of PA per week, and the converse was true for non-completers. Multivariate regression analyses showed that FRAT score was significantly associated with completion of FaME, and 180 degree turn and FES-I score were significantly associated with achieving the recommended 150 minutes of MVPA per week. Conclusions This study has shown that a significant increase in PA levels is only demonstrated in those who complete the FaME programme. Scores from selected functional measures and risk assessments are associated with FaME completion and achievement of 150 minutes of MVPA. This information can be used to provide targeted support to improve completion rates and physical activity levels of participants.

Background: Evidence regarding the impact of psychological problems on recovery from injury has limited influence on practice. Mindlines show effective practice requires diverse knowledge which is generally socially transmitted. Aims and objectives: Develop and test a method blending patient, practitioner, and research evidence and using Forum Theatre to enable key stakeholders to interact with it. Assess this methods; impact on contributing individuals/groups; on behaviour, practice, and research; mechanisms enabling these changes to occur. Methods: Stage-1: captured patient (n=53), practitioner (n=62), and research/expert (n=3) evidence using interviews, focus groups, literature review; combined these strands using framework analysis and conveyed them in a play. Stage-2: patients (n=32), carers (n=3), practitioners (n=31), and researchers (n=16) attended Forum Theatre workshops where they shared experiences, watched the play, re-enacted elements, and co-produced service improvements. Stage-3: used the Social Impact Framework to analyse study outcome data and establish what changed, how and why. Findings: This approach enhanced individuals'/group knowledge of post-injury psychopathology, confidence in their knowledge, mutual understanding, creativity, attitudes towards knowledge mobilisation, and research. These cognitive, attitudinal, and relational impacts led to multilevel changes in behaviour, practice, and research. Four key mechanisms enabled this research to occur and create impact: diverse knowledge, drama/storytelling, social interaction, actively altering outcomes. Discussion and conclusions: Discourse about poor uptake of scientific evidence focuses on methods to aid translation and implementation; this study shows how mindlines can reframe this 'problem' and inform impactful research. EPPIC demonstrated how productive interaction between diverse stakeholders using creative means bridges gaps between evidence, knowledge, and action.

Background: Unintentional home injuries are a leading cause of preventable death in young children. Safety education and equipment provision improve home safety practices, but their impact on injuries is less clear. Between 2009 and 2011 a national home safety equipment scheme was implemented in England (Safe At Home), targeting high injury rate areas and socio-economically disadvantaged families with children under 5. This provided a ‘natural experiment’ for evaluating the scheme’s impact on hospital admissions for unintentional injuries.Methods: Controlled interrupted time series analysis of unintentional injury hospital admission rates in small areas (Lower layer Super-Output Areas (LSOAs)) in England where the scheme was implemented (intervention areas, n=9,466)) matched with LSOAs in England and Wales where it was not implemented (control areas, n=9,466), with subgroup analyses by density of equipment provision.Results: 57,656 homes receiving safety equipment were included in the analysis. In the two years after the scheme ended, monthly admission rates declined in intervention areas (-0.33% (-0.47% to -0.18%)) but did not decline in control areas (0.04% (-0.11% to 0.19%), p value for difference in trend=0.001)). Greater reductions in admission rates were seen as equipment provision density increased. Effects were not maintained beyond two years after the scheme ended.Conclusions: A national home safety equipment scheme was associated with a reduction in injury-related hospital admissions in children under 5 in the 2-years after the scheme ended. Providing a higher number of items of safety equipment appears to be more effective in reducing injury rates than providing fewer items.

Additional file 1: Supplementary material 1. Matrix of behaviour determinants, performance and change objectives and behaviour change techniques (BCTs).

Background: Obesity and diabetes are major public health problems. Current approaches to weight loss show varying success. Complex community‐based interventions work through several interconnected stages. An individual’s actions in response to an intervention depend on many known and unknown factors, which vary among individuals.Aim: To conduct a realist synthesis to identify in which context, for whom, in what circumstances, and how weight loss interventions work in obese or overweight individuals with type 2 diabetes.Methods: A total of 49 trials identified during a systematic review were subsequently analysed using realist methodology. This iterative process involved hypothesis generation about how participants within a particular context respond to an intervention’s resources producing the outcomes. We used established behaviour change theory to look for repeating themes. Theory and ‘mechanisms’ were tested against the literature on what is shown to be effective. Where established theory was lacking, we discussed issues during discussion groups with individuals living with the condition to generate our own programme theories.Results: Mechanisms that were repeatedly identified included high‐frequency contact with those delivering the intervention, social support, education increasing awareness of diabetes‐related modifiable risk factors, motivational interviewing and counselling, goal‐setting, self‐monitoring and feedback and meal replacements. The central theme underlying successful mechanisms was personalizing each intervention component to the participants’ gender, culture and family setting.Conclusion: This is the first comprehensive realist synthesis in this field. Our findings suggest that, for weight loss interventions to be successful in those with diabetes, they must be personalized to the individual and their specific context.

Additional file 2: Supplementary material 2. Participant Handbook

The EarlyCDT-Lung test is a high-specificity blood-based autoantibody biomarker that could contribute to predicting lung cancer risk. We report on the results of a phase IV biomarker evaluation of whether using the EarlyCDT-Lung test and any subsequent computed tomography (CT) scanning to identify those at high risk of lung cancer reduces the incidence of patients with stage III/IV/unspecified lung cancer at diagnosis compared with the standard clinical practice at the time the study began. The Early Diagnosis of Lung Cancer Scotland (ECLS) trial was a randomised controlled trial of 12 208 participants at risk of developing lung cancer in Scotland in the UK. The intervention arm received the EarlyCDT-Lung test and, if test-positive, low-dose CT scanning 6-monthly for up to 2 years. EarlyCDT-Lung test-negative and control arm participants received standard clinical care. Outcomes were assessed at 2 years post-randomisation using validated data on cancer occurrence, cancer staging, mortality and comorbidities. At 2 years, 127 lung cancers were detected in the study population (1.0%). In the intervention arm, 33 out of 56 (58.9%) lung cancers were diagnosed at stage III/IV compared with 52 out of 71 (73.2%) in the control arm. The hazard ratio for stage III/IV presentation was 0.64 (95% CI 0.41–0.99). There were nonsignificant differences in lung cancer and all-cause mortality after 2 years. ECLS compared EarlyCDT-Lung plus CT screening to standard clinical care (symptomatic presentation) and was not designed to assess the incremental contribution of the EarlyCDT-Lung test. The observation of a stage shift towards earlier-stage lung cancer diagnosis merits further investigations to evaluate whether the EarlyCDT-Lung test adds anything to the emerging standard of low-dose CT., A positive EarlyCDT-Lung test, followed by CT, significantly reduced the numbers of late-stage cancers: performance of the blood test should be assessed further in a screening study where all eligible participants in the intervention arm have a CT scan https://bit.ly/32maUrB

Supplemental material, sj-pdf-1-cre-10.1177_0269215520971777 for A study of mapping usual care and unmet need for vocational rehabilitation and psychological support following major trauma in five health districts in the UK by Jade Kettlewell, Stephen Timmons, Kay Bridger, Denise Kendrick, Blerina Kellezi, Jain Holmes, Priya Patel and Kate Radford in Clinical Rehabilitation

Additional file 1. Keeping Active Interview Guide.

Background: The Step-Wise Approach for Treating Intention Tremor 2 (SWAT-IT₂) is a revised version of the original SWAT-IT that has been developed for broader application. This study aims to test the feasibility and clinical utility of the SWAT-IT₂ in the community and to determine if the SWAT-IT₂ impacts participants’ satisfaction of function, perceived function and self-efficacy. Methods: Using the SWAT-IT₂ protocol, one-on-one sessions were conducted with seven participants with Multiple Sclerosis (MS)-related IT. The protocol was applied to the daily functional activities. Data was collected using a demographic questionnaire (DQ), medical status questionnaire (MSQ), the new generalized self-efficacy scale (NGSE), the Multidimensional Assessment of Tremor (MAT), Expanded Disability Status Scale (EDSS), Symbol Digits Modalities Test (SDMT), and Tremor Treatment Techniques Visual Analog Scales (T³-VAS), and the Daily Tremor Evaluation Form (DTEval). Descriptive statistics were used to analyse the data. Results: Seven participants received the SWAT-IT₂ protocol. Most participants found the SWAT-IT₂ techniques easy to use and incorporate into their daily lives. After a month of using the techniques, the majority of participants reported increased satisfaction with their performance and less tremor interference in their daily lives. No clinically significant changes in self-efficacy were found. Conclusions: This study adds to the literature surrounding nonpharmacological, noninvasive interventions for MS-related IT by providing a feasible and effective intervention protocol addressing functional activities.

Objectives: To explore factors associated with maintenance of moderate-to-vigorous physical activity (MVPA) in community-dwelling adults aged ?65 years after completing a 24-week exercise programme.Study design: Cohort study nested within a randomised controlled trial evaluating group and home-based exercise programmes for older people in England.Methods: MVPA levels and factors potentially associated with physical activity (PA) were self-reported at recruitment, 6, 12, 18 and 24 months post exercise programme. Multilevel logistic regression estimated odds ratios for achieving target MVPA level (150 minutes/week) 6-24 months after exercise programmes ended.Results: Older people (OR per year increase: 0.89, 95%CI 0.86, 0.93) and women (OR 0.47, 95%CI 0.33, 0.67) were less likely to achieve target MVPA. Those physically active at recruitment (OR 11.28, 95%CI 7.95, 16.01), with wider social networks (OR per unit increase in Lubben Social Network Scale: 1.06, 95%CI 1.03, 1.10) and performing more sit-to-stands in 30 seconds (OR for quartile 3 compared to quartile 1: 1.87, 95%CI 1.12, 3.10) were more likely to achieve target MVPA. Negative exercise expectations increased the odds of achieving target MVPA, but only amongst the less active at recruitment (OR per unit increase in Outcome and Expectation for Exercise Negative Subscale: 1.90, 95%CI 1.39, 2.60). Associations did not differ significantly across the follow-up period.Conclusion: A range of factors are associated with maintenance of PA 6-24 months after exercise programmes. Factors are not more strongly associated with shorter versus longer term PA maintenance. Commissioners and providers should consider targeting maintenance interventions to those least likely to maintain PA.

Interview schedule. Question guide for semi-structured interviews. (DOCX 14â kb)

Supplemental digital content is available in the text., Background Physical activity (PA) has many health benefits but may increase falls risk among older adults. We study how objectively measured habitual daily PA is related to falls by exploring the modifying effect of mobility limitations and the mediating roles of fitness and lower-limb strength. Methods One thousand six hundred fifty-five (53%) of 3137 surviving participants (men age 71–91 yr) in an ongoing UK-population-based cohort study wore an ActiGraph GT3x accelerometer over the hip for 1 wk in 2010–2012 to measure PA (exposure) and reported demographic and health status, including mobility limitations. One year later, 825 men reported falls history (outcome). Results Seven hundred of 825 men had ≥600 min·d−1 of accelerometer wear for ≥3 d. Nineteen percent (n = 128) reported falls 1 yr later. Associations between PA and falls differed by presence of mobility limitations. Among 66% (n = 471) of men without mobility limitations, number of falls increased incrementally (for every 30 min of moderate to vigorous PA [MVPA]: incidence rate ratio [IRR], 1.50; 95% confidence interval [CI], 1.10–2.03, adjusted for falls risk factors). Step count was not related to number of falls below 9000 steps per day but was related to number of falls ≥9000 steps per day (for every additional 1000 steps per day: IRR, 1.59; 95% CI, 1.16–2.18). Among 33% (n = 229) of men with mobility limitations, falls risk declined with increasing activity (for every 1000 steps per day: IRR, 0.80; 95% CI, 0.70–0.91; for every 30 min of MVPA: IRR, 0.61; 95% CI, 0.42–0.89; for every additional 30 min of sedentary behavior ≥600 min·d−1: IRR, 1.22; 95% CI, 1.07–1.40). Conclusions Interventions to promote MVPA in older men should incorporate falls prevention strategies. Among adults with mobility limitations, trials should investigate whether increasing MVPA levels can reduce falls risk.

Figure schedule of enrolment, interventions, and assessments. (DOC 53Â kb)

Sensitivity Analyses (SA). (DOCX 13Â kb)

Key assumptions. (DOCX 12Â kb)

Background: Regular physical activity (PA) reduces the risk of falls and hip fractures, and mortality from all causes. However, PA levels are low in the older population and previous intervention studies have demonstrated only modest, short-term improvements.Objective: To evaluate the impact of two exercise promotion programmes on PA in people aged ≥ 65 years.Design: The ProAct65+ study was a pragmatic, three-arm parallel design, cluster randomised controlled trial of class-based exercise [Falls Management Exercise (FaME) programme], home-based exercise [Otago Exercise Programme (OEP)] and usual care among older people (aged ≥ 65 years) in primary care.Setting: Forty-three UK-based general practices in London and Nottingham/Derby.Participants: A total of 1256 people ≥ 65 years were recruited through their general practices to take part in the trial.Interventions: The FaME programme and OEP. FaME included weekly classes plus home exercises for 24 weeks and encouraged walking. OEP included home exercises supported by peer mentors (PMs) for 24 weeks, and encouraged walking.Main outcome measures: The primary outcome was the proportion that reported reaching the recommended PA target of 150 minutes of moderate to vigorous physical activity (MVPA) per week, 12 months after cessation of the intervention. Secondary outcomes included functional assessments of balance and falls risk, the incidence of falls, fear of falling, quality of life, social networks and self-efficacy. An economic evaluation including participant and NHS costs was embedded in the clinical trial.Results: In total, 20,507 patients from 43 general practices were invited to participate. Expressions of interest were received from 2752 (13%) and 1256 (6%) consented to join the trial; 387 were allocated to the FaME arm, 411 to the OEP arm and 458 to usual care. Primary outcome data were available at 12 months after the end of the intervention period for 830 (66%) of the study participants.The proportions reporting at least 150 minutes of MVPA per week rose between baseline and 12 months after the intervention from 40% to 49% in the FaME arm, from 41% to 43% in the OEP arm and from 37.5% to 38.0% in the usual-care arm. A significantly higher proportion in the FaME arm than in the usual-care arm reported at least 150 minutes of MVPA per week at 12 months after the intervention [adjusted odds ratio (AOR) 1.78, 95% confidence interval (CI) 1.11 to 2.87; p = 0.02]. There was no significant difference in MVPA between OEP and usual care (AOR 1.17, 95% CI 0.72 to 1.92; p = 0.52). Participants in the FaME arm added around 15 minutes of MVPA per day to their baseline physical activity level. In the 12 months after the close of the intervention phase, there was a statistically significant reduction in falls rate in the FaME arm compared with the usual-care arm (incidence rate ratio 0.74, 95% CI 0.55 to 0.99; p = 0.042). Scores on the Physical Activity Scale for the Elderly showed a small but statistically significant benefit for FaME compared with usual care, as did perceptions of benefits from exercise. Balance confidence was significantly improved at 12 months post intervention in both arms compared with the usual-care arm. There were no statistically significant differences between intervention arms and the usual-care arm in other secondary outcomes, including quality-adjusted life-years. FaME is more expensive than OEP delivered with PMs (£269 vs. £88 per participant in London; £218 vs. £117 in Nottingham). The cost per extra person exercising at, or above, target was £1919.64 in London and £1560.21 in Nottingham (mean £1739.93).Conclusion: The FaME intervention increased self-reported PA levels among community-dwelling older adults 12 months after the intervention, and significantly reduced falls. Both the FaME and OEP interventions appeared to be safe, with no significant differences in adverse reactions between study arms.Trial registration: This trial is registered as ISRCTN43453770.

Background There is a need to shed light on the pathways through which complex interventions mediate their effects in order to enable critical reflection on their transferability. We sought to explore and understand key stakeholder accounts of the acceptability, likely impact and strategies for optimizing and rolling-out a successful pharmacist-led information technology-enabled (PINCER) intervention, which substantially reduced the risk of clinically important errors in medicines management in primary care. Methods Data were collected at two geographical locations in central England through a combination of one-to-one longitudinal semi-structured telephone interviews (one at the beginning of the trial and another when the trial was well underway), relevant documents, and focus group discussions following delivery of the PINCER intervention. Participants included PINCER pharmacists, general practice staff, researchers involved in the running of the trial, and primary care trust staff. PINCER pharmacists were interviewed at three different time-points during the delivery of the PINCER intervention. Analysis was thematic with diffusion of innovation theory providing a theoretical framework. Results We conducted 52 semi-structured telephone interviews and six focus group discussions with 30 additional participants. In addition, documentary data were collected from six pharmacist diaries, along with notes from four meetings of the PINCER pharmacists and feedback meetings from 34 practices. Key findings that helped to explain the success of the PINCER intervention included the perceived importance of focusing on prescribing errors to all stakeholders, and the credibility and appropriateness of a pharmacist-led intervention to address these shortcomings. Central to this was the face-to-face contact and relationship building between pharmacists and a range of practice staff, and pharmacists’ explicitly designated role as a change agent. However, important concerns were identified about the likely sustainability of this new model of delivering care, in the absence of an appropriate support network for pharmacists and career development pathways. Conclusions This embedded qualitative inquiry has helped to understand the complex organizational and social environment in which the trial was undertaken and the PINCER intervention was delivered. The longitudinal element has given insight into the dynamic changes and developments over time. Medication errors and ways to address these are high on stakeholders’ agendas. Our results further indicate that pharmacists were, because of their professional standing and skill-set, able to engage with the complex general practice environment and able to identify and manage many clinically important errors in medicines management. The transferability of the PINCER intervention approach, both in relation to other prescribing errors and to other practices, is likely to be high.

In 1995, younger and more idealistic, I wrote an editorial in Injury Prevention asking where papers could be found describing intervention programs in such a way that they could be replicated.1 Now, many years later, I have an answer to this question—but it’s a negative answer: not in Injury Prevention . Perhaps space considerations make …

Background Falling is common among older people. The Timed-Up-and-Go Test (TUG) is recommended as a screening tool for falls but its predictive value has been challenged. The objectives of this study were to examine the ability of TUG to predict future falls and to estimate the optimal cut-off point to identify those with higher risk for future falls. Methods This is a prospective cohort study nested within a randomised controlled trial including 259 British community-dwelling older people ≥65 years undergoing usual care. TUG was measured at baseline. Prospective diaries captured falls over 24 weeks. A Receiver Operating Characteristic curve analysis determined the optimal cut-off point to classify future falls risk with sensitivity, specificity, and predictive values of TUG times. Logistic regression models examined future falls risk by TUG time. Results Sixty participants (23%) fell during the 24 weeks. The area under the curve was 0.58 (95% confidence interval (95% CI) = 0.49-0.67, p = 0.06), suggesting limited predictive value. The optimal cut-off point was 12.6 seconds and the corresponding sensitivity, specificity, and positive and negative predictive values were 30.5%, 89.5%, 46.2%, and 81.4%. Logistic regression models showed each second increase in TUG time (adjusted for age, gender, comorbidities, medications and past history of two falls) was significantly associated with future falls (adjusted odds ratio (OR) = 1.09, 95% CI = 1.00-1.19, p = 0.05). A TUG time ≥12.6 seconds (adjusted OR = 3.94, 95% CI = 1.69-9.21, p = 0.002) was significantly associated with future falls, after the same adjustments. Conclusions TUG times were significantly and independently associated with future falls. The ability of TUG to predict future falls was limited but with high specificity and negative predictive value. TUG may be most useful in ruling in those with a high risk of falling rather than as a primary measure in the ascertainment of risk.

Background\ud \ud Sedentary behaviour is detrimental to health, even in those who achieve recommended levels of physical activity. Efforts to increase physical activity in older people so that they reach beneficial levels have been disappointing. Reducing sedentary behaviour may improve health and be less demanding of older people, but it is not clear how to achieve this. We explored the characteristics of sedentary older people enrolled into an exercise promotion trial to gain insights about those who were sedentary but wanted to increase activity. \ud \ud Method\ud \ud Participants in the ProAct65+ trial (2009–2013) were categorised as sedentary or not using a self-report questionnaire. Demographic data, health status, self-rated function and physical test performance were examined for each group. 1104 participants aged 65 & over were included in the secondary analysis of trial data from older people recruited via general practice. Results were analysed using logistic regression with stepwise backward elimination. \ud \ud Results\ud \ud Three hundred eighty seven (35 %) of the study sample were characterised as sedentary. The likelihood of being categorised as sedentary increased with an abnormal BMI (25 kg/m2) (Odds Ratio 1.740, CI 1.248–2.425), ever smoking (OR 1.420, CI 1.042–1.934) and with every additional medication prescribed (OR 1.069, CI 1.016–1.124). Participants reporting better self-rated physical health (SF-12) were less likely to be sedentary; (OR 0.961, 0.936–0.987). Participants’ sedentary behaviour was not associated with gender, age, income, education, falls, functional fitness, quality of life or number of co-morbidities. \ud \ud Conclusion\ud \ud Some sedentary older adults will respond positively to an invitation to join an exercise study. Those who did so in this study had poor self-rated health, abnormal BMI, a history of smoking, and multiple medication use, and are therefore likely to benefit from an exercise intervention.

Unintentional injuries in childhood are a major cause of mortality and morbidity. Numerous risk factors for unintentional injury have been identified over recent years, and there have been several suggestions that injury prevention programmes should be targeted at children identified as high risk, based on these risk factors. There has also been increasing interest in, and emphasis on, the role of members of the primary health care team in preventing unintentional injuries to children, including within recent government policy. There is some evidence, so far, that primary care interventions can be effective in reducing hazards, increasing knowledge and changing behaviour. There is however, less evidence that they can be effective in reducing injury frequency or severity, with very few studies of high quality addressing this issue. The objectives of the research presented in this thesis are: 1.) to examine the relationship between accident and emergency department attendance and future hospital admission following unintentional injury, and to consider the transmission of injury data between secondary and primary care and the uses of such data within primary care; 2.) to examine the associations between risk factors for childhood injury and a variety of injury outcomes and to calculate the sensitivity, specificity and positive predictive value for risk factors in identifying children who will subsequently suffer an unintentional injury, and to consider high risk group and whole population strategies for injury prevention in the light of the findings; 3.) to assess knowledge, attitudes and current practices in childhood injury prevention amongst members of the primary health care team and to consider the implications of the findings for injury prevention in primary care. The first objective has been achieved by a matched case-control study. The main findings were that children who had been admitted to hospital following an unintentional injury were twice as likely to have previously attended the accident and emergency (A&E) department than community controls. However, only one third of hospital admissions had a history of previous A&E department attendance, hence most of the children admitted to hospital would not have been identified using A&E attendance. Current practice in many A&E departments is that a paediatric liaison health visitor notifies the community health visitor of children attending A&E following injury. Most authors in the field discuss post injury follow up visits as an appropriate response to receipt of such notifications, but there is little evidence for their effectiveness, and several studies show such visits are perceived to be difficult for both parents and health visitors. There is little evidence that, at present, injury data transmitted from secondary care is collated in a systematic way, to be used in primary care for needs assessment or injury surveillance. It is therefore recommended that the role of the paediatric liaison health visitor in the collection and transmission of injury data is in need of further consideration, and that post injury follow up visits require further study to demonstrate their effectiveness. The second objective has been achieved by a cross sectional survey followed by a cohort study. The main findings from this study are that only previous injury and male sex were associated with A&E department attendance and only previous injury with primary health care team attendance, despite sufficient power to demonstrate associations for several other risk factors. Consequently the sensitivity and positive predictive value of the risk factors in identifying children who will suffer previous injury was found to be low. The specificity was high for most risk factors, suggesting they will miss most children who will have injuries but will correctly identify most children who will not suffer future injury. The number of children needing to be targeted with an intervention to prevent one injury was similar for most risk factors, and similar to that if the whole population received an intervention. The results could not be adequately explained by bias, confounding or insufficient power Further work examining associations between risk fectors and unintentional injury in childhood is needed with larger sample sizes and in a population with a wide cross section of socioeconomic status to confirm these findings. At present, it is recommended that injury prevention programmes in primary care use a population approach. The third objective was achieved by a cross sectional survey of general practitioners, practice nurses and health visitors in Nottinghamshire. The main findings from this survey were that health visitors had a significantly higher score for knowledge of childhood unintentional injury epidemiology than general practitioners or practice nurses. They held significantly more positive attitudes to, and were undertaking significantly more injury prevention than, both general practitioners and practice nurses. Despite this both general practitioners and practice nurses held positive attitudes to at least some injury prevention activities. The activities most commonly undertaken were those using a preventive model of health education, for all professional groups. Activities involving empowerment or radical or political models of health education were used less often. There was little evidence of a systematic approach to injury prevention, with prevention occurring most often opportunistically. For all activities, and across all professional groups, a greater proportion of respondents agreed that an activity should be undertaken than actually undertook that activity, suggesting there may be barriers to undertaking injury prevention in primary care. The difference between the proportion agreeing an activity should be undertaken and doing so, was greatest for lobbying or campaigning and for collecting injury data. The conclusions from this study are that current injury prevention practice, which often uses a preventive model of health education, often as an isolated approach, and most often opportunistically, may not be the most effective strategy for reducing unintentional injuries in primary care. Further studies are needed to assess the effectiveness of primary health care team interventions offered systematically, using a combination of health education models and approaches. Such studies must address the barriers to injury prevention in primary care. The findings from this study suggest there is already some knowledge, and positive attitudes towards injury prevention, amongst at least some primary health care team members, on which to build interest in such future research. NB. This ethesis has been created by scanning the typescript original and contains some inaccuracies. In case of difficulty, please refer to the original text.